Percutaneous nephrolithotomy for staghorn kidney stones in elderly patients

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1 Int Urol Nephrol (2011) 43: DOI /s UROLOGY ORIGINAL PAPER Percutaneous nephrolithotomy for staghorn kidney stones in elderly patients Baris Kuzgunbay Tahsin Turunc Ozgur Yaycioglu Aliye Atay Kayis Umit Gul Tulga Egilmez Cem Aygun Hakan Ozkardes Received: 2 September 2010 / Accepted: 6 December 2010 / Published online: 29 December 2010 Ó Springer Science+Business Media, B.V Abstract Purpose We retrospectively analyzed the results of percutaneous nephrolithotomy operations for treatment of staghorn kidney stone disease in elderly patients and compared surgical parameters and outcomes with a control group of young adult patients. Patients and method Between 2002 and 2010, 300 consecutive patients underwent percutaneous B. Kuzgunbay (&) T. Turunc O. Yaycioglu U. Gul T. Egilmez C. Aygun H. Ozkardes School of Medicine, Department of Urology, Baskent University, Ankara, Turkey kuzgunbay33@yahoo.com T. Turunc drtahsinturunc@yahoo.com O. Yaycioglu yaycioglu@yahoo.com U. Gul umitgul@yahoo.com T. Egilmez tulgaegilmez@yahoo.com C. Aygun ccaygun@yahoo.com H. Ozkardes ozkardes@baskent.edu.tr A. A. Kayis School of Economic and Administrative Sciences, Department of Econometrics, Suleyman Demirel University, Isparta, Turkey aliyekayis@yahoo.com nephrolithotomy operation for treatment of staghorn kidney stone disease. Forty-five of the patients were older than 65 years and considered to be in elderly group. Thirty-seven of the patients were between the ages 18 and 36 years and considered to be the control group. Surgical parameters and outcomes were compared between groups. Results There were no significant differences between groups for stone area, operation time, difference in hemoglobin levels before and after surgery, blood transfusion rate, and length of hospital (P = 0.230, P = 0.106, P = 0.395, P = 0.691, and P = 0.690, respectively). Success rates after the operations were 53% in elderly group and 38% in young adult group. The difference for the outcomes of the operations was statistically insignificant (P = 0.365). Thirty-three (73%) of the patients had associated comorbid diseases in elderly group, while no patients had any comorbid disease in control group. Statistical analyses revealed no significant relation between the presence of comorbid diseases or ipsilateral renal surgery with success rate of the operation in the elderly group (P = 0.26 and P = 0.222, respectively). Conclusions The management of kidney stone disease by percutaneous nephrolithotomy in elderly patients is an adequate treatment modality even in the presence of complete staghorn calculi, comorbid diseases or previous ipsilateral renal surgery. Keywords Nephrolithotomy Percutaneous Elderly Staghorn Kidney stone

2 640 Int Urol Nephrol (2011) 43: Introduction Elderly person is commonly defined as a person who is at the age of 65 years or older [1]. However, the number of elderly patients treated for urinary stone disease increases as the life expectancy of human beings increases. The management of urinary stones in the elderly patient population holds some problems that include the risk of anesthesia, physiological changes, and comorbid diseases. Staghorn stones are especially a cause for concern since the treatment of such stones may involve lengthy and multiple procedures. Percutaneous nephrolithotomy is a safe and effective procedure in the management of staghorn calculi, with outcomes similar to those reported for percutaneous management of smaller volume non-staghorn stones [2]. In this study, we retrospectively analyzed the results of PCNL operations for the treatment of staghorn kidney stones in elderly patients. We also compared the surgical parameters and outcomes with a control group in young adult patients. Patients and method Patients Between 2002 and 2010, 300 patients underwent PCNL for the treatment of staghorn kidney stones in our institution. Forty-five of these patients were older than 65 years and were considered as the elderly group. Forty-seven PCNL operations were performed to these 45 patients since two patients had bilateral staghorn kidney stones. Thirty-seven patients who were between the ages of 18 and 36 years were designed as the control group. The kidney stones were diagnosed by intravenous pyelography (IVU) and/or computerized tomography (CT). Stones filling the renal pelvis and all calyces were defined as staghorn calculi. In order to calculate the total stone area, the area of each stone part located in the calyces and the pelvis was calculated separately and then added. The area of each stone part was calculated by multiplying the largest vertical and horizontal diameter in millimeters as seen on a plain radiogram. Associated comorbid diseases were also recorded. Patients with urinary tract infection were treated by culture-specific antibiotic treatment before surgery. All patients were treated with short-term prophylactic antibiotic treatment before the surgery. Intensive medical care facilities were also provided liberally after the operation. Operations All of the operations were performed in a single center under general anesthesia. After ureteral catheter insertion in the lithotomy position, the patients were tilted to prone position. The pyelocalyceal system was approached with the insertion of an 18-gauge Chiba needle under fluoroscopic guidance. Tract dilation was achieved via either Amplatz or balloon dilators (MarFlowÒ, Switzerland) after placement of a safety guide-wire in place. At the end of dilation, a 30 F renal sheath was placed, and rigid nephroscopy was performed. A pneumatic lithotripter was used for stone fragmentation. The stone fragments were mechanically extracted, and a 16 F re-entry nephrostomy catheter was placed at the end of the operation. Outcomes Operation time was derived from the anesthesia chart and defined as the time elapsed in minutes from the induction of anesthesia until the insertion of nephrostomy catheter. The difference of hemoglobin (DHb), calculated by subtracting the hemoglobin value after surgery from the value before surgery, was used for the evaluation of blood loss. Postoperative outcome was evaluated using a plain X-ray performed on the morning after the procedure. The outcomes of the operation were evaluated in three categories; stone free (SF), clinically insignificant residual fragments (CIRF, residual fragments smaller than 4 mm), and clinically significant residual fragments (CSRF, residual fragments larger than 4 mm). Success rate was defined as the sum of SF and CIRF. The nephrostomy catheter was withdrawn following an antegrade pyelography performed on the 2nd day after surgery and/or after the gross hematuria cleared. Hospitalization time was defined as the number of days the patient spent at the hospital starting from the day of surgery. For the patients who required additional treatment for stone clearance after PCNL, the type and the outcome of additional treatment were recorded. The final stone status of the patients was evaluated using CT 3 months after the operation.

3 Int Urol Nephrol (2011) 43: Table 1 The operation parameters according to groups Parameters Elderly group Control group P values Age 69 ± 3.5 years 27 ± 5 years Stone area 1,684.6 ± mm 2 1,503.9 ± mm Operation time ± 36.0 min ± 37.3 min Blood transfusion rate 5 (10.6%) 5 (13.5%) DHb 1.46 ± 1.29 gr/dl 1.70 ± 1.33 gr/dl Length of hospital stay 3.8 ± 2.3 days 3.9 ± 1.1 days The surgical parameters and outcomes were compared between elderly and the control group. Statistical analysis Statistical analysis of data was performed with Statistical Package for Social Sciences (SPSS) for Windows and Splus 6.2 program. In this study, parametric and non-parametric statistical tests were used. For the comparisons of mean differences of two independent groups, two independent t-tests (or z-test) were used when the assumptions were satisfied. On the other case (assumptions were not satisfied), the corresponding non-parametric test called Mann Whitney U test was used to test if two independent groups were coming from the populations with the same median. Two independent t-tests for qualitative variables were used to test the ratio differences between two (independent) groups. The Chi-square test was also used for the independence test between some qualitative variables. P values\0.05 were considered to be statistically significant. Results There were 23 males and 22 females in elderly and 18 males and 19 females in the control groups, respectively. Percutaneous nephrolithotomy was performed to 29 (62%) left and 18 (38%) right kidneys in elderly group, and 13 (35%) left and 24 (65%) right kidneys in the control group. The mean age, stone area, operation time, hospitalization time, DHb, blood transfusion rates for both of the groups, and the corresponding p values are presented in Table 1. Statistical analyses showed no significant differences between elderly and control group for stone area, operation time, DHb, blood transfusion rate, and length of hospital stay. The access numbers of the groups were presented in Table 2 Number of accesses according to groups Number of access Elderly group (n) Control group (n) 1 access 33 (70%) 19 (51%) 2 accesses 10 (21%) 14 (38%) 3 accesses 4 (19%) 4 (11%) Intercostal access (11 12th rib) 5 (10.5%) 4 (11%) Table 3 The outcomes of the groups Outcomes Elderly group Control group SF 17 (36%) 9 (24.3%) CIRF 8 (17%) 5 (13.5%) Success rate 25 (53%) 14 (37.8%) CSRF 22 (47%) 23 (62.2%) Success rate (3rd month) 43(91.5%) 34 (92%) SF Stone free, CIRF Clinically insignificant residual fragments, CSRF Clinically significant residual fragments Table 2. The outcomes of operations for both groups are shown in Table 3. The overall success rates (SF and CIRF) were 53% for elderly and 37.8% for control groups. Statistical analysis revealed no significant differences between the outcomes of the operations (P = 0.365). In the elderly group, 18 (38.3%) of 22 patients with CSRF required additional treatment after PCNL; 3 (6.4%) of them underwent second-look PCNL, while 15 (31.9%) of them underwent extracorporeal shock wave lithotripsy (SWL). After SWL sessions, all of the patients became stone free. Three patients underwent secondary PCNL operation 1 week after the initial operation using the same access. The other 4 (8.5%) patients who had CSRF were followed up without any treatment. At 3-month follow-up in the elderly group, 35 (74.5%) renal units became stone free, 8 (17%) had CIRF, and 4 (8.5%)

4 642 Int Urol Nephrol (2011) 43: had CSRF; thus, the overall success rate was 91.5%. One of the patients, who had CSRF and was followed without any treatment, required secondary PCNL 18 months after the initial operation. In the control group, no patient underwent second-look PCNL, while 20 (54%) of the patients underwent SWL as an additional treatment after PCNL. Three (8.2%) of the patients who had CSRF were followed without any treatment. After SWL sessions, 15 (75%) of them became stone free, while the others had CIRF and were followed up. At 3-month follow-up in the young adult group, 24 (65%) of the patients became stone free, 10 (27%) had CIRF, and 3 (8%) had CSRF; thus, the overall success rate was 92%. Statistical analysis revealed no significant difference between groups for additional treatment requirements (P = 0.434). In elderly group, 4 (9%) of the patients had ipsilateral renal surgery in history, while 7 (19%) of the patients had in control group. Statistical analysis revealed no significant relation between the presence of ipsilateral renal surgery and success rate of the operation neither in the elderly group nor in the control group (P = 0.222). Thirty-three (73%) of the elderly patients had at least one comorbid condition such as, diabetes mellitus, hypertension, or atherosclerotic coronary artery disease, while no patients had any comorbid diseases in the control group. In elderly group, statistical analyses revealed no significant relation between the presence of comorbid diseases and success rate of the operation (P = 0.26). No major perioperative complications were seen like sepsis, pneumothorax, or bowel injury. However, minor complications were seen as needing blood transfusions in 5 patients in elderly and 5 patients in control group (Grade 2 due to Modified Clavien Classification) [3]. Stone analysis revealed whewellite and weddellite stones in 23 (49%), struvite in 4 (8.5%) of the elderly, while whewellite and weddellite stones in 17 (46%), struvite in 3 (8%), cystin in 3 (8%) of the young adult patients. Discussion There are limited number of published studies concerning the management of urinary stones with PCNL in the elderly patient population [4 9]. Kandel advocated PCNL for the treatment of kidney stones larger than 2.5 cm in the elderly patients in 1990 [4]. In 1994, Stoller and coworkers reported the results of 42 PCNL operations performed on 33 patients aged 65 years and older and compared them with a cohort of 160 PCNL operations performed on younger patients over the same time period [5]. Only 17 of 36 renal units (47%) had complete staghorn kidney stones in this study. Eighty-two percent of patients (27 of 33) were stone free or had fragments\5 mm at 3 months after surgery. The transfusion rate was higher in the elderly patients. In 2001, Sahin and coworkers reported the result of PCNL on 27 patients older then 60 years and compared them with 178 PCNL procedures performed on 166 patients over the same time period [6]. Only 25% of the patients had complete staghorn kidney stones. The success rates (stone free or left with fragments \4 mm) were 89% for the elderly and 92% for the younger patients (P = 0.718). Transfusion rates were 21% in the elderly and 18% in the younger patients (P = 0.662). The largest series on PCNL in elderly patients was reported by Dore and coworkers in 2005 [7]. This multicentre study presented retrospective data of 203 patients over the age of 70, in whom a total of 210 PCNL were performed over a 12-year period in ten referral centers. Comorbid diseases were seen in 68.5% of the cases. The median stone dimensions were mm, and 40 (19%) of the patients had staghorn stones. The overall stone-free rate was 70.8%, while it was only 30.8% for patients with complete staghorn stones. They also detected that diabetes mellitus influenced the stone-free rate (P = 0.03). The stone-free rate for complete staghorn stones of this study is similar to ours. Also, the percentage of cases with comorbid diseases in this paper is similar to ours, which is 73%. On the other hand, we did not detect any significant relation between the presence of comorbid diseases and success rate of the operations in elderly patients. Jou and coworkers reported the safety of tubeless PCNL in 50 patients aged older than 70 years with kidney stone diseases [8]. They concluded that tubeless PCNL does not increase the complication rate in elderly patients. In this study, the rate of the staghorn kidney stones was not presented. In a recent study, Anagnostou and coworkers reported no statistically important differences between the elderly (over 69 years) and control (17 69 years) groups in terms of stone burden before surgery, adverse events rates, complete stone-free

5 Int Urol Nephrol (2011) 43: rates, and clinical success rates. However, a statistical trend toward higher clinical success rates in favor of the younger group was seen (P = 0.051) [9]. In our study, the insignificant difference between elderly and control groups among stone area reflects the comparability of the groups in terms of stone load. The length of hospital stay, mean delta Hb, blood transfusion rate, success rate (SF and CIRF), and the need for additional treatments after PCNL were similar for the elderly and control groups indicating that older age did not have a negative effect on the surgical parameters and outcome of the PCNL operation. Although higher stone-free rates (78 93%) for staghorn kidney stones after treatment of PCNL were reported in large series in the literature, the definition of their staghorn calculi includes both partial and complete staghorn kidney stones [2, 10]. Adversely, we included only complete staghorn kidney stones in our study. Additionally, lower SF rates of our patients in both groups might be explained by lower surgeon experience at the beginning and technical limitations such as using only pneumatic lithotripter and the lack of flexible nephroscope. However, the final success rates had reached reasonable levels after additional treatments. In our study, the presence of comorbid diseases and ipsilateral renal surgery in history did not have any negative effect on the success rate of the operations in elderly patients. The fact that no major perioperative complication was encountered except blood transfusion in both of the groups indicates that PCNL procedure can safely be performed in elderly patients with staghorn kidney stones. Conclusion The management of kidney stone disease by percutaneous nephrolithotomy in elderly patients is an adequate treatment modality even in the presence of complete staghorn calculi. However, surgeons have to follow all of the safety principals of endourological surgery with a great attention. Conflict of interest References There is no conflict of interest. 1. World Health Organization (2009) Definition of an older or elderly person. Health statistics and health information systems. World Health Survey, 2009; healthinfo/survey/ageingdefnolder/en/index.html 2. Soucy F, Ko R, Duvdevani M et al (2009) Percutaneous nephrolithotomy for staghorn calculi: a single center s experience over 15 years. J Endourol 23(10): Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2): Kandel LB (1990) Treatment of renal calculi in the elderly. Am J Kidney Dis 16: Stoller ML, Bolton D, St Lezin M, Lawrence M (1994) Percutaneous nephrolithotomy in the elderly. Urology 44: Sahin A, Atsu N, Erdem E et al (2001) Percutaneous nephrolithotomy in patients aged 60 years or older. J Endourol 15: Doré B, Conort P, Irani J, Comité Lithiase de l Association Française d Urologie et al (2004) Percutaneous nephrolithotomy (PCNL) in subjects over the age of 70: a multicentre retrospective study of 210 cases. Prog Urol 14: Jou YC, Lin CT, Shen CH et al (2009) Tubeless percutaneous nephrolithotomy for elderly patients. Urol Int 82: Anagnostou T, Thompson T, Ng CF et al (2008) Safety and outcome of percutaneous nephrolithotomy in the elderly: retrospective comparison to a younger patient group. J Endourol 22(9): Desai M, Jain P, Ganpule A et al (2009) Developments in technique and technology: the effect on the results of percutaneous nephrolithotomy for staghorn calculi. BJU Int 104(4):